Publications (60)153.58 Total impact
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Article: The Pulmonary Side of Reflux Disease: from Heartburn to Lung Fibrosis.
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ABSTRACT: INTRODUCTION: Gastroesophageal reflux disease (GERD) is the most prevalent gastrointestinal disorder in the USA. Heartburn is the symptom most commonly associated with this disease, and the highly commercialized medical treatment directed toward relief of this symptom represents a 10-billion-dollar-per-year industry. DISCUSSION: Unfortunately, there is often little awareness that GERD can be potentially a lethal disease as it can cause esophageal cancer. Furthermore, there is even less awareness about the relationship between GERD and respiratory disorders with the potential for severe morbidity and even mortality.Journal of Gastrointestinal Surgery 04/2013; · 2.83 Impact Factor -
Article: Role of Extended Lymphadenectomy in Cancer of the Gastrointestinal Tract.
World Journal of Surgery 04/2013; · 2.36 Impact Factor -
Article: Extended Lymphadenectomy in Esophageal Cancer is Debatable.
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ABSTRACT: Surgery is an essential part of the treatment of patients with esophageal carcinoma. However, there is no consensus on whether the surgical technique can be improved to promote better survival outcome. Specifically, the real value of the addition of a radical lymphadenectomy to the esophageal resection is still elusive and controversial. This paper focuses on the debate of esophagectomy and lymphadenectomy for the treatment of esophageal cancer.World Journal of Surgery 04/2013; · 2.36 Impact Factor -
Article: New trends and concepts in diagnosis and treatment of achalasia.
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ABSTRACT: The last 2 decades have witnessed a revolution in the treatment of esophageal achalasia. Nowadays, laparoscopic Heller myotomy with partial fundoplication is considered in most centers the primary treatment modality, while endoscopic treatment, i.e. pneumatic dilatation, is mainly reserved for the management of patients unfit for surgery or in case of surgical failure. Recently, a new approach to achalasia has been proposed: the peroral endoscopic myotomy (POEM), which combines the advantages of endoscopy and surgery. This article reviews the evolution of the diagnosis and treatment of esophageal achalasia during the last 20 years.Cirugía Española 04/2013; · 0.87 Impact Factor -
Article: Outcomes of laparoscopic nissen fundoplication in patients with manometric patterns of esophageal motility disorders.
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ABSTRACT: The manometric pattern of either diffuse esophageal spasm (DES), nutcracker esophagus (NE), or hypertensive lower esophageal sphincter (HLES) in the presence of gastroesophageal reflux disease (GERD) is considered a secondary finding and treatment should be directed toward GERD. This study aims to evaluate the outcomes of laparoscopic Nissen fundoplication (LNF) in patients with manometric patterns of esophageal motility disorders. Patients with GERD confirmed by pH monitoring and manometric pattern of DES (simultaneous contractions 20 to 90% of wet swallows), NE (increased mean distal amplitude greater than 180 mmHg), or HLES (lower esophageal sphincter pressure greater than 45 mmHg) who underwent LNF were studied. A group of 50 consecutive patients with normal esophageal motility who underwent LNF were used as control subjects. Groups were comparable to control subjects for age, gender, preoperative symptoms, hiatal hernia, and Barrett's esophagus, except for NE that had younger individuals and a lower rate of hiatal hernia. Symptomatic outcome was similar when groups were compared with control subjects. Transient dysphagia was present in the postoperative period in 33, 7, 0, and 20 per cent of the patients with HLES, DES, NE, and control subjects, respectively. LNF is an adequate treatment for patients with GERD and manometric patterns of esophageal motility disorders.The American surgeon 04/2013; 79(4):361-5. · 1.28 Impact Factor -
Article: Laparoscopic heller myotomy and fundoplication in patients with chagas´ disease achalasia and massively dilated esophagus.
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ABSTRACT: Laparoscopic Heller myotomy and fundoplication is considered today the treatment of choice for achalasia. The optimal treatment for end-stage achalasia with esophageal dilation is still controversial. This multicenter and retrospective study aims to evaluate the outcome of laparoscopic Heller myotomy in patients with a massively dilated esophagus. Eleven patients (mean age, 56 years; 6 men) with massively dilated esophagus (esophageal diameter greater than 10 cm) underwent a laparoscopic Heller myotomy and anterior fundoplication between 2000 and 2009 at three different institutions. Preoperative workup included upper endoscopy, esophagram, and esophageal manometry in all patients. Average follow-up was 31.5 months (range, 3 to 60 months). Two patients (18%) had severe dysphagia, four patients (36%) had mild and occasional dysphagia to solid food, and five patients (45%) were asymptomatic. All patients gained or kept body weight, except for the two patients with severe dysphagia. Of the two patients with severe dysphagia, one underwent esophageal dilatation and the other a laparoscopic esophagectomy. They are both doing well. Heller myotomy relieves dysphagia in the majority of patients even when the esophagus is massively dilated.The American surgeon 01/2013; 79(1):72-5. · 1.28 Impact Factor -
Article: Multidisciplinary approach for patients with esophageal cancer.
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ABSTRACT: Patients with esophageal cancer have a poor prognosis because they often have no symptoms until their disease is advanced. There are no screening recommendations for patients unless they have Barrett's esophagitis or a significant family history of this disease. Often, esophageal cancer is not diagnosed until patients present with dysphagia, odynophagia, anemia or weight loss. When symptoms occur, the stage is often stage III or greater. Treatment of patients with very early stage disease is fairly straight forward using only local treatment with surgical resection or endoscopic mucosal resection. The treatment of patients who have locally advanced esophageal cancer is more complex and controversial. Despite multiple trials, treatment recommendations are still unclear due to conflicting data. Sadly, much of our data is difficult to interpret due to many of the trials done have included very heterogeneous groups of patients both histologically as well as anatomically. Additionally, studies have been underpowered or stopped early due to poor accrual. In the United States, concurrent chemoradiotherapy prior to surgical resection has been accepted by many as standard of care in the locally advanced patient. Patients who have metastatic disease are treated palliatively. The aim of this article is to describe the multidisciplinary approach used by an established team at a single high volume center for esophageal cancer, and to review the literature which guides our treatment recommendations.World Journal of Gastroenterology 12/2012; 18(46):6737-46. · 2.47 Impact Factor -
Article: Impact of minimally invasive surgery on the treatment of benign esophageal disorders.
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ABSTRACT: Thanks to the development of minimally invasive surgery, the last 20 years have witnessed a change in the treatment algorithm of benign esophageal disorders. Today a laparoscopic operation is the treatment of choice for esophageal achalasia and for most patients with gastroesophageal reflux disease. Because the pathogenesis of achalasia is unknown, treatment is palliative and aims to improve esophageal emptying by decreasing the functional obstruction at the level of the gastro-esophageal junction. The refinement of minimally invasive techniques accompanied by large, multiple randomized control trials with long-term outcome has allowed the laparoscopic Heller myotomy and partial fundoplication to become the treatment of choice for achalasia compared to endoscopic procedures, including endoscopic botulinum toxin injection and pneumatic dilatation. Patients with suspected gastroesophageal reflux need to undergo a thorough preoperative workup. After establishing diagnosis, treatment for gastroesophageal reflux should be individualized to patient characteristics and a decision about an operation made jointly between surgeon and patient. The indications for surgery have changed in the last twenty years. In the past, surgery was often considered for patients who did not respond well to acid reducing medications. Today, the best candidate for surgery is the patient who has excellent control of symptoms with proton pump inhibitors. The minimally invasive approach to antireflux surgery has allowed surgeons to control reflux in a safe manner, with excellent long term outcomes. Like achalasia and gastroesophageal reflux, the treatment of patients with paraesophageal hernias has also seen a major evolution. The laparoscopic approach has been shown to be safe, and durable, with good relief of symptoms over the long-term. The most significant controversy with laparoscopic paraesophageal hernia repair is the optimal crural repair. This manuscript reviews the evolution of these techniques.World Journal of Gastroenterology 12/2012; 18(46):6764-70. · 2.47 Impact Factor -
Article: Predictors of Unsuccessful Laparoscopic Resection of Gastric Submucosal Neoplasms.
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ABSTRACT: BACKGROUND: While laparoscopy has become integral to the performance of foregut surgery, its optimal use in resection of gastric submucosal neoplasms, including gastrointestinal stromal tumors (GISTs), remains uncertain. Concern exists for technical feasibility related to tumor size and location, as well as oncologic outcome. METHODS: From 2002 to 2012, 106 patients underwent resection for gastric submucosal neoplasms, comprising 79 laparoscopic and 27 open resections. Median follow-up was 15 months. RESULTS: Patients were 62 ± 14 years and 56 % male. Mean tumor size was 5.5 ± 4.3 cm, with 76 % being GISTs. A total of 8 (10 %) conversions occurred in the laparoscopic cohort. On multivariate analysis, conversion was predicted by size greater than 8 cm, while recurrence was predicted by mitotic index (p < 0.05). Laparoscopic resection resulted in better perioperative outcomes, with less morbidity, operative time, blood loss, and length of stay (p < 0.05). No significant difference was seen in survival, with 90 % and 81 % alive 3 years after laparoscopic and open resection, respectively (HR 0.4; 95 % CI 0.1-1.3; p = 0.13). CONCLUSIONS: Laparoscopic resection is feasible and effective in the management of gastric submucosal neoplasms, including GISTs. Caution should be reserved for tumors greater than 8 cm. Oncologic outcome appears to be predicted by tumor biology as opposed to surgical approach.Journal of Gastrointestinal Surgery 12/2012; · 2.83 Impact Factor -
Article: Laparoscopic Total Fundoplication for Gastroesophageal Reflux Disease. How I Do It.
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ABSTRACT: INTRODUCTION: A laparoscopic fundoplication is considered today the procedure of choice for the treatment of gastroesophageal reflux disease (GERD). DISCUSSION: Several eponyms are used in the literature to denote different antireflux operations: Nissen, Nissen-Rossetti, Toupet, Lind, Guarner, Hill, and Dor. We feel that it is more important to focus on the technical elements which make a fundoplication effective and long lasting. The type of fundoplication (total vs. partial) is tailored to the quality of esophageal peristalsis as documented by the preoperative manometry. In the USA, a partial fundoplication is chosen only for patients with very impaired or absent esophageal peristalsis. CONCLUSION: This article describes the technique of laparoscopic total fundoplication for GERD. Partial fundoplication is performed following the same technical elements as the total fundoplication. A 240° to 270° wrap rather than a 360° wrap is performed.Journal of Gastrointestinal Surgery 11/2012; · 2.83 Impact Factor -
Article: Gastroesophageal Reflux Disease and Antireflux Surgery-What Is the Proper Preoperative Work-up?
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ABSTRACT: BACKGROUND: Many surgeons feel comfortable performing antireflux surgery (ARS) on the basis of symptomatic evaluation, endoscopy, and barium esophagography. While esophageal manometry is often obtained to assess esophageal peristalsis, pH monitoring is rarely considered necessary to confirm the diagnosis of gastroesophageal reflux disease (GERD). AIMS: The aim of this study was to analyze the sensitivity and specificity of symptoms, endoscopy, barium esophagography, and manometry as compared to pH monitoring in the preoperative evaluation of patients for ARS. PATIENTS AND METHODS: One hundred and thirty-eight patients were referred for ARS with a diagnosis of GERD based on symptoms, endoscopy, and/or barium esophagography. Barium esophagography, esophageal manometry, and ambulatory 24-h pH monitoring were performed preoperatively in every patient. RESULTS: Four patients were found to have achalasia and were excluded from the analysis. Based on the presence or absence of gastroesophageal reflux on pH monitoring, the remaining 134 patients were divided into two groups: GERD+ (n = 78, 58 %) and GERD- (n = 56, 42 %). The groups were compared with respect to the incidence of symptoms, presence of reflux and hiatal hernia on esophagogram, endoscopic findings, and esophageal motility. There was no difference in the incidence of symptoms between the two groups. Within the GERD+ group, 37 patients (47 %) had reflux at the esophagogram and 41 (53 %) had no reflux. Among the GERD- patients, 17 (30 %) had reflux and 39 (70 %) had no reflux. A hiatal hernia was present in 40 and 32 % of patients, respectively. Esophagitis was found at endoscopy in 16 % of GERD+ patients and in 20 % of GERD- patients. Esophageal manometry showed no difference in the pressure of the lower esophageal sphincter or quality of peristalsis between the two groups. CONCLUSIONS: The results of this study showed that (a) symptoms were unreliable in diagnosing GERD, (b) the presence of reflux or hiatal hernia on esophagogram did not correlate with reflux on pH monitoring, (c) esophagitis on endoscopy had low sensitivity and specificity, and (d) manometry was mostly useful for positioning the pH probe and rule out achalasia. Ambulatory 24-h pH monitoring should be routinely performed in the preoperative work-up of patients suspected of having GERD in order to avoid unnecessary ARS.Journal of Gastrointestinal Surgery 10/2012; · 2.83 Impact Factor -
Article: The evolution of the treatment of esophageal achalasia: a look at the last two decades.
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ABSTRACT: Thanks to the development of minimally invasive surgery, the last 20 years have witnessed a revolution in the treatment of benign esophageal disorders, particularly for esophageal achalasia. This has brought a shift in the treatment algorithm of this disease, as today a laparoscopic Heller myotomy with partial fundoplication is considered the primary form of treatment in most Centers in North America. This article reviews the evolution of the treatment of esophageal achalasia during the last two decades, with particular stress on the key technical elements of this operation.Updates in surgery. 07/2012; 64(3):161-5. -
Article: High resolution manometry findings in patients with esophageal epiphrenic diverticula.
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ABSTRACT: The pathophysiology of esophageal epiphrenic diverticula is still uncertain even though a concomitant motility disorder is found in the majority of patients in different series. High resolution manometry may allow detection of motor abnormalities in a higher number of patients with esophageal epiphrenic diverticula compared with conventional manometry. This study aims to evaluate the high resolution manometry findings in patients with esophageal epiphrenic diverticula. Nine individuals (mean age 63 ± 10 years, 4 females) with esophageal epiphrenic diverticula underwent high resolution manometry. A single diverticulum was observed in eight patients and multiple diverticula in one. Visual analysis of conventional tracings and color pressure plots for identification of segmental abnormalities was performed by two researchers experienced in high resolution manometry. Upper esophageal sphincter was normal in all patients. Esophageal body was abnormal in eight patients; lower esophageal sphincter was abnormal in seven patients. Named esophageal motility disorders were found in seven patients: achalasia in six, diffuse esophageal spasm in one. In one patient, a segmental hypercontractile zone was noticed with pressure of 196 mm Hg. High resolution manometry demonstrated motor abnormalities in all patients with esophageal epiphrenic diverticula.The American surgeon 12/2011; 77(12):1661-4. · 1.28 Impact Factor -
Article: Esophageal achalasia 2011: pneumatic dilatation or laparoscopic myotomy?
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ABSTRACT: This article reviews the changes that have taken place in the treatment of patients with achalasia in the last 20 years. It compares and contrasts treatment preferences in the USA with those of Canada and Europe. It provides a critical analysis of the recent randomized trial between laparoscopic Heller myotomy and pneumatic dilatation that was carried out in several European centers. It supports the use of laparoscopic Heller myotomy as the preferred treatment for the average patient with this disease in the USA.Journal of Gastrointestinal Surgery 10/2011; 16(4):870-3. · 2.83 Impact Factor -
Article: Laparoscopic excision of esophageal leiomyoma.
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ABSTRACT: Esophageal leiomyoma is the most common benign tumor of the esophagus. The lower and middle thirds of the esophagus are the most frequent locations of these tumors and in about one-third of the patients they occur at the level of the gastroesophageal junction. They are less than 5 cm in size in 50% of the patients. A left thoracotomy, thoracoscopy or a laparoscopic approach can be used for lesions in the lower third of the esophagus. Esophageal leiomyomas should be considered for resection when symptomatic. Preoperative evaluation allows precise characterization of the diagnosis and location. Minimally invasive surgery is considered today the treatment of choice with the laparoscopic approach used for distal tumors. We present the case of a 63-year-old woman with an esophageal leiomyoma located above the gastroesophageal junction who underwent a successful laparoscopic excision of the tumor.Updates in surgery. 09/2011; -
Article: Modern pathophysiology and treatment of esophageal diverticula.
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ABSTRACT: Esophageal diverticula are rare. They may occur in the pharyngoesophageal area (Zenker's), midesophagus, or distally (epiphrenic). A motility disorder (either at the level of the esophageal sphincters or body) is frequently associated with esophageal diverticula. The risk of malignant transformation is low. A literature search was performed using Medline/PubMed database. The treatment of esophageal diverticula must be based on the pathophysiology and natural history of the disease: (a) asymptomatic diverticula do not need a specific treatment, (b) small diverticula may be left in place and not resected, (c) medium-size diverticula may be either treated by diverticulectomy, diverticulopexy, or esophagodiverticulostomy in case of pharyngoesophageal diverticula, (d) resection is probably the ideal therapy for larger diverticula, and (e) a myotomy should always be included to the procedure. Due to its rarity, esophageal diverticula must be treated by esophageal surgeons since even in experienced hands the complication rate can be significant.Langenbeck s Archives of Surgery 09/2011; 397(1):29-35. · 1.81 Impact Factor -
Article: Patti MG, Herbella FA. fundoplication after laparoscopic heller myotomy for esophageal achalasia: What type? J Gastrointest Surg. 2010 Sept.;14(9):1453-8.
Journal of Gastrointestinal Surgery 08/2011; 15(11):2121. · 2.83 Impact Factor -
Article: Interstitial lung disease and gastroesophageal reflux disease: key role of esophageal function tests in the diagnosis and treatment.
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ABSTRACT: Gastroesophageal reflux disease (GERD) is common in patients with respiratory disorders and interstitial lung fibrosis from diverse disease processes. However, a cause-effect relationship has not been well demonstrated. It is hypothesized that there might be more than a coincidental association between GERD and interstitial lung damage. There is still confusion about the diagnostic steps necessary to confirm the presence of GERD, and about the role of effective control of GERD in the natural history of these respiratory disorders. To determine the prevalence of GERD in patients with respiratory disorders and lung involvement; the sensitivity of symptoms in the diagnosis of GERD; and the role of esophageal function tests (manometry and 24- hour pH monitoring) in the diagnosis and treatment of these patients. Prospective study based on a database of 44 patients (29 females) with respiratory disorders: 16 patients had idiopathic pulmonary fibrosis, 11 patients had systemic sclerosis associated interstitial lung disease, 2 patients had polymyositis associated interstitial lung disease, 2 patients had Sjögren associated interstitial lung disease, 2 patients had rheumatoid artrithis associated interstitial lung disease, 1 patient had undifferentiated connective tissue diseases associated interstitial lung disease and 10 patients had sarcoidosis. The average forced vital capacity (% predicted) was 64.3%. All patients had esophageal function tests. Thirty patients (68%) had pathologic reflux (average DeMeester score: 45, normal <14.7). The average number of reflux episodes recorded 20 cm above the lower esophageal sphincter was 24. Sensitivity and specificity of heartburn were 70% and 57%, of regurgitation 43% and 57%, and of dysphagia 33% and 64%. Twelve patients with GERD underwent a laparoscopic fundoplication which was tailored to the manometric profile: three patients in which peristalsis was normal had a total fundoplication (360°) and nine patients in which the peristalsis was absent had a partial anterior fundoplication (180°). The results of our study show that: (a) abnormal reflux was present in about 2/3 of patients with respiratory disorders (idiophatic pulmonary fibrosis, connective tissue disorders and sarcoidosis), and it extended to the upper esophagus in most patients; (b) the sensitivity and specificity of reflux symptoms was very low; and (c) esophageal function tests were essential to establish the diagnosis of abnormal reflux, to characterize the esophageal function and guide therapy. Long term follow-up will be necessary to determine if control of reflux alters the natural history of these respiratory disorders.Arquivos de gastroenterologia 06/2011; 48(2):91-7. -
Article: Helicobacter pylori has no influence on distal gastric cancer survival.
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ABSTRACT: There is some evidence that Helicobacter pylori correlates with distal gastric cancer genesis. However, few studies analyzed the survival related to H. pylori infection. To correlate gastric cancer survival and H. pylori infection. Sixty-eight patients with distal gastric cancer that underwent subtotal gastrectomy were studied. Minimal follow-up was 1 month. H. pylori infection was confirmed by biopsy. Thirty-four patients (19 males (55.9%), mean age 60.9 ± 14.03, range 33-82 years) were H. pylori positive. Thirty-four patients (16 males (47.1%), mean age 57.9 ± 13.97, range 27-85 years) were H. pylori negative. Groups were comparable in regards to age (P = 0.4), gender (P = 0.5), stage [T (P = 0.2), N (P = 0.6) and M (P = 0.9)]. Survival was not different when groups were compared [P = 0.1616 (hazard ratio 0.6834, 95% CI 0.4009 to 1.1647)]. H. pylori infection does not affect distal gastric cancer survival.Arquivos de gastroenterologia 06/2011; 48(2):109-11. -
Article: Postprandial proximal gastric acid pocket in patients after laparoscopic Nissen fundoplication.
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ABSTRACT: An unbuffered postprandial proximal gastric acid pocket (PPGAP) has been noticed in normal individuals and patients with gastroesophageal reflux disease (GERD). The role of gastric anatomy in the physiology of the PPGAP remains unclear. It is also unclear whether change in the PPGAP may contribute to GERD control. This study aims to analyze the presence of PPGAP in patients submitted to Nissen fundoplication. Fifteen patients who had a laparoscopic Nissen fundoplication (mean age = 61 years, 13 females, mean time from operation 1 year) were studied. All patients were free of foregut symptoms. Patients underwent high-resolution manometry to identify the location of the lower border of the lower esophageal sphincter (LBLES).Station pull-through pH monitoring was performed from 5 cm below the LBLES to the LBLES in increments of 1 cm in a fasting state and 10 min after a standardized fatty meal. Four patterns of gastric acidity were found: (1) acid was not detected in the studied area of the stomach in 8 (53%) patients; (2) constant acidity (stomach is not alkalinized after meal), i.e., a buffered layer was not found in 3 (20%) patients; (3) PPGAP was not detected, i.e., the whole stomach is alkalinized, in 1 (7%) patient; and (4) PPGAP was noted in 3 (20%) patients with extensions of 2, 2, and 5 cm. PPGAP is present in a minority of patients after Nissen fundoplication. This finding may explain part of the GERD control and that the gastric fundus may play a role in the genesis of the PPGAP.Surgical Endoscopy 04/2011; 25(10):3198-201. · 4.01 Impact Factor
Top co-authors
Top Journals
Institutions
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2010–2013
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University of Chicago
- Department of Surgery
Chicago, IL, USA
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2008–2013
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Universidade Federal de São Paulo
Guarulhos, Estado de Sao Paulo, Brazil -
Loyola University Medical Center
- Department of Surgery
Maywood, IL, USA
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2008–2012
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The University of Chicago Medical Center
- Section of Hematology/Oncology
Chicago, IL, USA
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2011
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Northwestern University
- Department of Surgery
Evanston, IL, USA -
Università degli studi di Palermo
Palermo, Sicily, Italy
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1998–2009
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University of California, San Francisco
- Department of Surgery
San Francisco, CA, USA
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